RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2013-02780
BRANCH OF SERVICE:  Army	BOARD DATE:  20150313
SEPARATION DATE:  20070110

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6 (Aircraft Power Train Repair) medically separated for pruritus ani with current fissures formation.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The “pruritus ani” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “pruritus ani with current fissures formation” as unfitting, rated 0%.  The CI made no appeals and was medically separated.

CI CONTENTION:  “it was/occurred during service.  I would of continued a long career but could not, conditions have not changed for the better.  These conditions have rendered/changed my life my quality of life decreases each year b/c of pain/discomfort, impacts me medically”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:

IPEB – Dated 20061117 | VA* - (~1 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Pruritus Ani With Current Fissures Formation | 7337 | 0% | Pruritus Ani | 7337-7336 | 10% | 20070207
Other x 0 (Not In Scope) | Other x 5
RATING:  0% | RATING:  50%
*Derived from VA Rating Decision (VARD) dated 20070621 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Pruritus Ani Condition.  The narrative summary notes the CI experienced anal itching (pruritus ani) and was treated with multiple topical and oral medications.  Notes in the service treatment record indicated that the CI reported itching and blood after bowel movements (BM) and was treated with various medications, eventually with both topical and oral medication for yeast infections.  The CI did well between a first and second deployment, however, his symptoms were exacerbated by his second deployment and he was diagnosed with anal fissures (tears).  When he returned from deployment he had a colonoscopy performed on 21 July 2006 for “pruritus ani and multiple episodes of rectal bleeding,” which noted “markedly decreased sphincter tone,” but was otherwise normal, including no evidence of hemorrhoids.  Biopsies from the colon and skin in the surrounding area were normal and laboratory tests for ova and parasites (O&P) were negative.  Despite the negative O&P tests, the medication profile indicated a course of anti-parasitic medication was prescribed.  At a follow-up visit on 9 August 2006, the CI reported persistent itching and abdominal pain after meals with frequent BM with urgency, and pertinent examination was unremarkable.  The surgeon diagnosed irritable bowel syndrome (IBS) and pruritus ani, and prescribed an intestinal muscle relaxant for the IBS.  The examiner commented that he was perplexed by the CI’s symptoms and supported initiation of a MEB.

At the MEB examination on 16 October 2006, 3 months prior to separation, the CI reported itching.  The MEB physical exam was normal, with no blood in the stool.  The examiner noted a blood count in August 2006 was normal, without evidence of anemia.  The examiner indicated the CI’s current condition included burning and pain, aggravated by prolonged standing or walking, which required additional periodic application of topical medication.

At the VA Compensation and Pension examination 7 February 2007, a month after separation, the CI reported pruritus (itching).  He was taking a course of oral medication for intestinal parasites, with no change in his symptoms yet.  The CI reported loose stools twice daily with onset at the same time as the pruritus in 2003.  The examination noted a normal abdominal exam without tenderness and no anal fissures or hemorrhoids.  Repeat testing for O&P in January 2007 was reportedly negative.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the pruritus ani condition 0%, coded 7337 (pruritus ani) and the VA rated it 10%, coded 7337-7336 (hemorrhoids with anal fissures).  The Board noted that the rating criteria of code 7337 are simply “rate for the underlying condition.”  Pruritus ani may be related to multiple conditions such as hemorrhoids, skin conditions, or irritation or trauma, including anal fissures.  Likewise anal fissures may be related to many underlying conditions, including any condition which causes trauma or irritation, such as frequent loose stools.  The VA rated analogously to hemorrhoids noting that despite no identified etiology, the CI’s ongoing symptoms were supportive of more than the 0% rating generally provided for pruritus ani “without significantly disabling symptoms.”  The Board was sympathetic to the VA reasoning that the CI’s symptoms suggested a higher rating than 0%, but considered that there was no evidence in record of any problem with hemorrhoids as the underlying condition.  However, the Board opined that it was logical to assume the noted gastrointestinal (GI) symptoms, which manifested at the same time as the pruritus ani, were related.  The working diagnosis of the GI symptoms in service was IBS.  Therefore, the Board considered rating the pruritus ani condition analogous to 7319 (irritable colon syndrome) for the underlying condition of IBS.  The rating criteria for 7319 are subjective with 0%, described as mild, with occasional episodes of abdominal distress or 10%, described as moderate, with frequent episodes.  The Board agreed that the evidence in record of cramping abdominal pain after meals and twice daily loose BM provides sufficient support for the 10%, moderate rating, but there was no evidence of constant abdominal distress to provide the next higher evaluation.  The Board next discussed the colonoscopy finding of “markedly decreased sphincter tone” with consideration of rating as 7332 (impairment of rectal and anal sphincter control).  However there was no evidence of bowel incontinence in this case, required for a rating greater than 10%.  Thus, the Board could find no path to a higher evaluation with any applicable code IAW §4.114 (digestive system).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the pruritus ani condition, coded 7337-7319.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the pruritus ani condition, the Board unanimously recommends a disability rating of 10%, coded 7337-7319 IAW VASRD §4.114.  There were no other conditions within the Board’s scope of review for consideration.

The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

CONDITION | VASRD CODE | RATING
Pruritus Ani Condition | 7337-7319 | 10%
COMBINED | 10%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131217, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX 
President 
DoD Physical Disability Board of Review

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXXXXXXX, AR20150012775 (PD201302780)

1.  I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation to modify the individual’s disability rating to 10% without recharacterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl			XXXXXXXXXXXXXXXXXXXX
				 Deputy Assistant Secretary of the Army
				      (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA

PD-2013-02780